Method for iron delivery to a patient by transfer from dialysate

ABSTRACT

The invention relates to methods and compositions for delivering iron to an iron-deficient patient, more particularly, to methods whereby an iron complex comprising divalent or trivalent ionic iron complexed with one or more low molecular weight anions is administered to a patient by transfer from dialysate. A complex selected according to the invention is non-polymeric; soluble in an aqueous medium; chemically stable, thereby preventing the dissociation of iron ions from the anions under conditions according to the invention; and can be well absorbed into blood and the living body. Also provided are dialysate compositions including therein an iron complex selected according to the invention, and dialysate concentrates which may be diluted to yield an inventive dialysate composition.

CROSS-REFERENCE TO PRIOR APPLICATIONS

The present application is a continuation of U.S. application Ser. No.08/869,331, filed Jun. 5, 1997, now U.S. Pat. No. 5,906,978, whichclaims priority to Provisional application No. 60/023,926, filed Aug.14, 1996.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates to methods and compositions for efficientlydelivering iron to a patient. More particularly, the present inventionis concerned with dialysates and dialysate concentrates, and methods fordelivering to a patient via dialysis a composition comprising ionic ironcomplexed with one or more anions. An iron complex selected according tothe invention is non-polymeric; soluble in an aqueous medium; chemicallystable, thereby preventing the dissociation of iron ions from the anionsunder conditions according to the invention; and can be well absorbed byblood and the living body.

2. Description of Related Art

Iron is a metal which is an essential requirement for tissue growth inhumans and many animals. Therefore, an adequate supply of iron iscritical to their survival and well-being. Although there is normally anample amount of iron in the diet, the level of absorption of iron fromfood is generally low and, therefore, the supply of iron to the body caneasily become critical under a variety of conditions. For example, ironis a necessary ingredient in the production of red blood cells, and alack of iron may quickly lead to anemia. Iron deficiency anemia iscommonly encountered, for example, in pregnancy and may also present aproblem in the newly born. Moreover, in certain pathological conditionsthere is a maldistribution of body iron leading to a state of chronicanemia. This is seen in chronic diseases such as rheumatoid arthritis,certain haemolytic diseases and cancer.

Anemia is also uniformly present in patients with end stage renaldisease (ESRD). The major cause of this anemia is the deficientproduction of erythropoeietin hormone (EPO) by the native kidneys. EPOstimulates the bone marrow to produce red cells, and when EPO isdeficient, patients invariably become anemic. To counter the anemia ofESRD patients, recombinant EPO (which is very expensive) may beadministered subcutaneously or intravenously. Recombinant EPO caneffectively increase the hematocrit of patients with adequate ironstores, but the increased rate of production of new red cells quicklydepletes body iron stores and, when this occurs, EPO becomes completelyineffective. As such, the delivery of iron to an ESRD patient iscritical to his or her treatment. Methods in the prior art fordelivering iron to a patient, such as an ESRD patient, have provenlargely impractical and unsatisfactory, and there is a great need forimproved methods of iron delivery.

It is well known that iron is very difficult to assimilate into thecells of a living organism and when an iron deficiency exists, oral ironsupplements in relatively large doses are commonly administered whereinthe iron may be in a wide variety of forms, i.e., usually as variousorganic and inorganic salts. Iron compositions which have beenpreviously administered orally include, for example, ferrous gluconate,ferrous citrate, ferrous sulfate, ferrous fumarate andferric-polysaccharide complexes. As a specific example of a conditionwhere oral iron delivery is common, ESRD patients are typically directedto take oral iron tablets when EPO is started, as discussed above.

Oral iron administration, however, has several disadvantages. Patientnoncompliance, gastrointestinal side effects, interactions with otheroral medications and very poor absorption in ESRD patients markedlylimit its effectiveness. For example, patients often stop taking thesemedications because of side effects associated therewith, such asconstipation and gastric irritation. Additionally, these oral ironpreparations cause a patient's stools to turn black, thereby making itdifficult for caregivers to detect gastrointestinal bleeding during irontherapy. It is believed that these problems are all related to theadministration of relatively high dosage levels of oral compounds due tothe low level of iron uptake by the body, and these high doses arethought to also cause siderosis of the gut wall.

To overcome the above-described problems with oral delivery of iron, agreat deal of effort has been directed to developing iron deliverymethods wherein iron-containing compositions are delivered parenterally,either by intravenous or intramuscular injection. In this regard, it iscurrently widely believed that compositions used for non-oral ironadministration must be in macromolecular form. This mindset is basedupon the belief that the use of macromolecules eliminates the problem ofosmolarity in the case of intramuscular injection, and, in the case ofintravenous injection, the belief that macromolecular compositions arerequired to ensure that free iron is not introduced into the blood.Since iron is slowly freed from such macromolecules by the action ofmetabolism, and then bound by transferrin in the blood as it slowlybecomes available, administration of iron in macromolecular forms ispresently thought to be the only viable option with respect tointravenous administration techniques.

With respect to intravenous administration, iron-dextran (INFED®), whichmay be obtained from Schein Pharmaceuticals, Phoenix, Ariz., is commonlyadministered intravenously to ESRD patients to increase iron stores,with about 100-200 mg injected each successive dialysis until about 1000mg are administered. Iron dextran is a macromolecule having a highaverage molecular weight ranging generally between about 100,000 andabout 200,000. However, iron dextran occasionally causes severe allergicreactions, fever and rashes during injection and must therefore beadministered slowly and after a small test dose. Ferric gluconate isanother macromolecular iron complex for intravenous administration, andis relatively free of symptoms. However, each of these intravenous ironpreparations is very expensive and requires a great deal of time andskill for administration. The large expense related to these intravenouspreparations is associated in part with the necessity for sterilizationof the injectant. Additionally, intravenous administration requiresvenous access, which is available during hemodialysis, but not commonlyavailable in peritoneal dialysis patients. Finally, only about half ofiron in iron dextran is bio-available after intravenous injection forred cell production. The fate of the rest is unknown.

With respect to intramuscular injection, iron dextrins and iron dextransmay be administered intramuscularly; however, as a result of their highmolecular weights, absorption in the human or animal body is incomplete.Furthermore, the administration of these compositions intramuscularly ispainful and often results in an undesirable discoloration at theinjection site. Alternatively, U.S. Pat. No. 3,686,397 to Muller teachesan iron preparation for intramuscular-injection which comprises anonionic complex of trivalent iron supplied a ferric hydroxide with acomplex forming agent consisting of sorbitol, gluconic acid and certainoligosaccharides (polyglucoses) in certain proportions and amounts.Other. macromolecular iron preparations which may be administered viaintramuscular injection are taught in U.S. Pat. No. 5,177,068 toCallingham et al., U.S. Pat. No. 5,063,205 to Peters et al., U.S. Pat.No. 4,834,983 to Hider et al. and U.S. Pat. No. 4,167,564 to Jenson.Many preparations, such as that taught in the Jenson patent, may beadministered parenterally either by intramuscular or intravenousinjection.

Recently, it has been proposed that iron may be administered to a mammalby intraperitoneal delivery of macromolecular iron dextran. It has beenfound that only about half of the iron delivered intraperitoneally inthis form is bioavailable, passing to the blood and then to thereticulo-endothelial system and bone marrow, where it is incorporatedinto red cells. It appears that about 50% of the iron dextran is storedpermanently in the body and is not avaialable for red cell production.There is evidence that macrophages near the peritoneum pick upiron-dextran and store it within themselves, creating an abnormalphysical condition which could lead to abnormal membrane changes in theperitoneum.

In light of this background, there is a great need in the art forimproved methods for delivering iron to a patient. The present inventionaddresses the problems in the prior art by providing methods andcompositions for delivering iron by transfer of a low molecular weight(non-polymeric) iron complex from dialysate. Inventive methods aresurprisingly effective in light of conventional thought, which teachesthat complexes selected according to the invention do not havesufficient solubility to be useful in this manner. Further, it is widelybelieved that soluble iron complexes are unacceptable iron deliveryagents, this belief being based upon a fear of the toxicity of free ironin blood.

The present inventor has discovered that iron complex compositionsselected in accordance with the invention are tightly complexed and arehighly soluble, and can thereby be safely administered to a patientusing dialysis with minimal staff effort and very little risk. This highsolubility also advantageously allows an inventive complex to beincluded in dialysate concentrates, which are described in greaterdetail herein. For hemodialysis applications, the iron can be added to adialysate or a concentrate just as other solutes, in “clean” form andneed not be sterilized. For peritoneal applications, the ironcomposition can be sterilized.

SUMMARY OF THE INVENTION

The present invention provides methods and compositions for deliveringiron to an iron-deficient patient. More particularly, the inventionrelates to delivering to a patient via dialysis a composition comprisingionic iron complexed with one or more anions, wherein the complex isnon-polymeric; soluble in an aqueous medium; chemically stable, therebypreventing the dissociation of iron ions from the anions underconditions according to the invention; and can be well absorbed by bloodand the living body.

According to one specific aspect of the invention, there is provided amethod for performing dialysis with a complex of one or more divalent ortrivalent iron ions and one or more anions, the complex having amolecular weight of less than about 50,000 and preferably beingnon-polymeric. This method of delivering iron to a patient comprisesproviding an aqueous dialysate having the complex dissolved therein, anddialyzing a patient with the dialysate to increase the level of iron inthe patient's blood. Inventive methods achieve this advantageous resultwithout introducing free iron into the blood. A preferred anionaccording to one aspect of the invention is an organic anion.

According to another aspect of the invention, there is provided a methodfor delivering iron to blood which comprises passing blood against afirst side of a membrane and passing against a second side of themembrane an aqueous solution having dissolved therein an iron complexcomprising one or more iron ions and one or more anions, the complexhaving a molecular weight of less than about 12,000; wherein themembrane is permeable to the complex and wherein the complex isdelivered to the blood.

According to another aspect of the invention, there is provided a methodfor increasing the level of iron in a patient's blood by introducing adialysate into a patient's peritoneal cavity, the dialysate comprising anon-polymeric complex of one or more divalent or trivalent iron ions andone or more anions, the complex having a molecular weight of less thanabout 50,000.

In another aspect of the invention, there is provided: a dialysatecomposition having dissolved therein sodium, magnesium, calcium,potassium, chloride, acetate, bicarbonate and an iron complex having amolecular weight of less than about 50,000. An inventive dialysatecomprises from about 130 to about 150 mEq/L sodium, from about 0.4 toabout 1.5 mEq/L magnesium, from about 2 to about 4 mEq/L calcium, fromabout 1 to about 4 mEq/L potassium, from about 90 to about 120 mEq/Lchloride, from about 3 to about 5 mEq/L acetate, from about 30 to about40 mEq/L bicarbonate and from about 1 to about 250 μg/100 ml of iron asan iron complex having a molecular weight of less than about 50,000.Also provided is a dialysate concentrate, prepared for subsequentdilution to a suitable concentration for use as a dialysate, preferablyhaving a concentration about 30 to about 40 times greater than theconcentration of the desired dialysate.

It is an object of the present invention to provide improved methods foradministering iron to a patient, especially a patient suffering fromchronic anemia and end stage renal disease.

Another object of the invention is to provide methods wherebyconventional hemodialysis techniques may be used to deliver iron to apatient without the need to sterilize the iron-containing compositionprior to administration.

It is also an object of the invention to provide methods for deliveringiron to peritoneal dialysis patients by providing a dialysate whichincludes sterile non-polymeric iron complexes according to theinvention.

Additionally, it is an object of the invention to provide dialysatecompositions which may be advantageously used to deliver iron to apatient by a wide variety of dialysis techniques and concentratesthereof.

Further objects, features, and advantages of the present invention shallbecome apparent from the detailed drawings and descriptions providedherein.

BRIEF DESCRIPTION OF THE DRAWINGS

Although the characteristic features of this invention will beparticularly pointed out in the claims, the invention may be betterunderstood by referring to the following descriptions taken inconnection with the accompanying drawings forming a part hereof.

FIG. 1 is a plot of iron concentration (μg/dl) in plasma versus elapsedtime in minutes in the experiment described in Example 1. The horizontalline at 234 μg/dl represents the capacity by transferrin in plasma tobind soluble iron, and the horizontal line at 125 μg/dl represents theconcentration of iron in the dialysate described in Example 1.

FIG. 2 is a plot of absorbance of plasma at 420 and 585 nm versuselapsed time in minutes, obtained as described in Example 2.

FIG. 3 is a plot of optical absorbance of ferrous gluconate at highconcentration (100 mg/dl) versus wavelength (nm), taken for theblood-leak detector experiment described in Example 3.

DESCRIPTION OF THE PREFERRED EMBODIMENT

For the purposes of promoting an understanding of the principles of theinvention, reference will now be made to the preferred embodiments andspecific language will be used to describe the same. It willnevertheless be understood that no limitation of the scope of theinvention is thereby intended. Any alterations and further modificationsin the described invention, and any further applications of theprinciples of the invention as described herein are contemplated aswould normally occur to one skilled in the art to which the inventionrelates.

The present invention overcomes problems in the prior art associatedwith delivering iron to a patient. Iron delivery according to theinvention is accomplished by providing a dialysate compositioncomprising a iron complex which is soluble in an aqueous medium anddelivering the complex to a patient using conventional dialysistechniques. An “iron complex,” as used herein, is intended to designatea composition comprising one or more iron ions complexed with one ormore suitable anions and having a molecular weight of less than about50,000. Inventive iron complexes are preferably non-polymeric

This invention, therefore, relates to surprisingly efficacious methodsfor delivering iron by providing a dialysate, the dialysateadvantageously being prepared either by on-site preparation or bydiluting a pre-made dialysate concentrate and the dialysate havingdissolved therein, among other solutes, a low molecular weightnon-polymeric iron complex; and dialyzing a patient therewith using oneof a wide variety of dialysis techniques. Inventive methods are usefulfor delivering iron to a patient in readily-available form and, sinceiron complexes according to the invention are relatively tightly bound,they may advantageously be delivered to a patient without risk ofintroducing free iron into the blood. It is contemplated that variouscompositions, compositional ratios, procedures, and processes describedin connection with the present invention could be altered or substitutedas would occur to those skilled in the art without departing from thespirit of the invention. It is believed that inventive methods mayadvantageously be used in conjunction with dialysis techniques currentlyin wide use, as well as improvements thereof, and with dialysistechniques yet to be developed. It is anticipated that the presentinvention may find particularly advantageous use in hemodialysisprocedures and intraperitoneal dialysis procedures.

With regard to specific examples of dialysis techniques, it is wellknown that conventional hemodialysis procedures may be performed infree-standing treatment centers, although they may also be provided in ahospital or performed by the patient at home. Conventional hemodialysiscircuits have two fluid pathways: the blood circuitry and the dialysatecircuitry. The blood circuitry conventionally comprises a 15-gaugeneedle for access to the circulation (usually through an arteriovenousfistula created in the patient's forearm), lengths of plasticizedpolyvinyl chloride tubing (including a special segment adapted to fitinto a peristaltic blood pump), the hemodialyzer itself, a bubble trapand an open mesh screen filter, various ports for sampling or pressuremeasurements at the blood outlet, and a return cannula. Access to thecirculation may alternatively be made at a single access point using adouble-lumen catheter. Components of the blood side circuit are suppliedin sterile and nonpyrogenic condition. The dialysate side typicallycomprises a machine capable of (1) proportioning out glucose andelectrolyte concentrates with water to provide a dialysate ofappropriate composition; (2) pulling dialysate past a restrictor valveand through the hemodialyzer at subatmospheric pressure; and (3)monitoring temperature, pressures, and flow rates.

During treatment the patient's blood is typically anticoagulated withheparin. Typical blood flow rates are about 200-350 ml/min and dialysateflow rates are usually set at about 500 ml/min. A dialysate volume ofabout 120-200 liters is typically used per dialysis treatment. Simpletechniques have been developed to prime the blood side with sterilesaline prior to use and to return to the patient nearly all the bloodcontained in the extracorporeal circuit after treatment. Whereas mostmass transport occurs by diffusion, circuits are typically operated witha pressure on the blood side, which may be 100-500 mmHg higher than onthe dialysate side. This provides an opportunity to remove 2-4 liters offluid along with solutes in a single treatment. Higher rates of fluidremoval are technically possible but physiologically unacceptable.Hemodialyzers must be designed with high enough hydraulic permeabilitiesto provide adequate fluid removal at low transmembrane pressure but notso high that excessive water removal will occur in the upper pressurerange.

Although other geometries may be employed, one preferred hemodialyzerformat is a “hollow fiber” hemodialyzer about 25 cm in length and 5 cmin diameter, resembling the design of a shell and tube heat exchanger.Blood enters this type of hemodialyzer at an inlet manifold, isdistributed to a parallel bundle of capillary tubes (typically pottedtogether with polyurethane), and exits at a collection manifold.Dialysate flows countercurrent in an external chamber. The shell istypically made of an acrylate or polycarbonate resin. Devices typicallycontain about 6000-10,000 capillaries, each with an inner diameter ofabout 200-250 microns and a dry wall thickness as low as about 10microns. The total membrane surface area in commercial dialyzerstypically varies from about 0.5 to about 1.5 m², and units can bemass-produced at a relatively low cost.

Although a specific hemodialysis set-up is described in detail above, itis well understood that a wide variety of hemodialysis devices may beadvantageously used in accordance with the invention. Examples ofalternate hemodialysis devices and methods suitable for use according tothe invention are set forth in U.S. Pat. No. 5,277,820 to Ash; U.S. Pat.No. 4,661,246 to Ash; U.S. Pat. No. 4,581,141 to Ash; U.S. Pat. No.4,348,283 to Ash; U.S. Pat. No. 4,071,444 to Ash et al.; U.S. Pat. No.3,734,851 to Matsumura; U.S. Pat. No. 4,897,189 to Greenwood et al.;U.S. Pat. No. 4,267,041 to Schael; U.S. Pat. No. 4,118,314 to Yoshida;U.S. Pat. No. 3,989,625 to Mason; and U.S. Pat. No. 3,962,075 toFialkoff et al. These patents are hereby incorporated herein byreference.

In a hemodialysis treatment, as discussed above, blood is removed fromthe body, propelled through a closed system of membranes, and returnedto the body, while on the other side of the membranes is an aqueousdialysis fluid. These membranes are semipermeable, allowing smallmolecules to pass through, but retaining larger molecules such asproteins, as well as cellular blood elements. Uremic substances, beingsmall molecules, will pass through the membranes as long as theconcentration of these substances is kept low in the dialysis fluid, ordialysate, on the other side of the membrane. The aqueous medium so usedmust be prior treated to remove trace elements (which would otherwisepass back across the membrane into the blood), must be supplemented withelectrolytes and glucose, and must then be warmed to blood temperature.The electrolytes are added to the dialysate so as to prevent excessiveion removal (i.e., Mg⁺⁺, K⁺, Na⁺, Cl⁻ and HCO₃ ⁻). Calcium ions shouldalso be in slight excess in the dialysate so as to cause addition ofcalcium to the patient's blood, as the total body calcium in kidneyfailure patients is often low, leading to stimulation of parathyroidhormone, which is detrimental to the patient's health.

In one preferred aspect of the present invention, a non-polymeric ironcomplex is used according to the invention in conventionalextracorporeal hemodialysis techniques by providing a dialysate, forexample, as described above, having the iron complex dissolved thereinto a predetermined concentration. An iron complex to be dissolved intodialysate for hemodialysis must be “clean,” but need not be sterile, asis the case for other solutes in a dialysate. This provides asubstantial advantage over prior methods of iron delivery to a patientby intramuscular or intravenous injection, both of which necessitatethat the iron preparation be sterilized prior to injection. Thedialysate, having a clean iron complex dissolved therein will deliverthe iron complex to the blood during dialysis by diffusion, at a rateautomatically responding to the blood plasma concentration, just as theconcentrations of other solutes (such as, for example, sodium,potassium, glucose, bicarbonate, magnesium, calcium and chloride) areadjusted in dialysate to assure proper plasma levels in a patient. Inthe case of inventive iron complexes, however, it appears that bloodproteins are binding the complex, thereby removing the complex from theplasma water and maintaining a concentration gradient between thedialysate and the blood. Basis for this theory is found in Example 1 andFIG. 1, where it is shown that the total amount of ferrous gluconatetransferred to blood is higher than that expected based upon simpleconcentration gradient analysis. Thus, transfer of an inventive ironcomplex to the blood will continue until the level of free iron complexin the plasma reaches the same concentration as the iron complexdissolved in dialysate.

Turning now to an alternate dialysis technique, another type of dialysiswith which inventive methods may be advantageously used is continuousambulatory peritoneal dialysis (CAPD), also referred to hereininterchangeably as “peritoneal dialysis” or “intraperitoneal dialysis.”In this type of dialysis, approximately 2 liters of a sterile,nonpyrogenic, and hypertonic solution of glucose and electrolytes areinstilled via gravity flow into the peritoneal cavity of a patientthrough an indwelling catheter, typically 4 times per day.Intraperitoneal fluid partially equilibrates with solutes in the plasma,and plasma water is ultrafiltered due to osmotic gradients. After about4-5 hours, except at night where the exchange is lengthened to about9-11 hours to accommodate sleep, the peritoneal fluid is drained and theprocess repeated. Patients may perform the exchanges themselves in about20-30 minutes, for example at home or in the work environment, after atraining cycle which usually lasts about 1-2 weeks. Alternatively,automated peritoneal dialysis (APD) may be used, in which case about10-15 liters of dialysate are automatically exchanged overnight and 2liters remain in the peritoneal cavity during the day for a “long dwell”exchange.

Access to the peritoneum is usually via a double-cuff Tenckhoffcatheter, essentially a 50-100 cm length of silicone tubing with sideholes at the internal end, a dacron mesh flange at the skin line, andconnector fittings at the end of the exposed end. A wide variety ofvariations exist, however, and may advantageously be used in accordancewith the invention. Most are implanted in a routine surgical procedurerequiring about 1 hour and are allowed to heal for about 1-2 weeks priorto routine clinical use. Sterile and nonpyrogenic fluid is commonlysupplied in 2 liter containers fabricated from dioctyl phthalateplasticized polyvinyl chloride. The formulation is essentiallypotassium-free lactated Ringers to which has been added from about15-42.5 grams/liter of glucose (dextrose monohydrate). The solution isbuffered to a pH of about 5.1-5.5, since the glucose would caramelizeduring autoclaving at higher pH levels.

Several different exchange protocols may be used in a peritonealdialysis procedure. In one conventional design, the patient simply rollsup the empty bag after instillation and then drains into the same bagfollowing exchange. The bag filled with drain fluid is disconnected anda fresh bag is reconnected. Patients are trained to use aseptictechnique to perform the connect and disconnect. Many aids have beendeveloped to assist in minimizing breaches of sterility includingenclosed ultraviolet-sterilized chambers and heat. splicers. More recentapproaches, known as the “O” set and “Y” set or more generically as“flush before fill” disconnect, invoke more complex tubing sets to allowthe administration set to be flushed (often with antiseptic) prior toinstillation of dialysate and generally permit the patient to disconnectthe empty bag during the dwell phase. Initial reports of the success ofthese protocols in reducing peritonitis were regarded with skepticism,but improvement over earlier systems has now been documented inwell-designed and carefully controlled clinical trials.

Iron complexes selected in accordance with the invention may also beadministered to a patient from dialysate intraperitoneally, for example,as described above. While dialysates used for intraperitoneal dialysismust be sterilized prior to use, this aspect of the invention alsoprovides an excellent manner in which to introduce iron complexes into apatent's blood in an advantageous form. In intraperitoneal dialysistechniques, just as in hemodialysis techniques, a smaller iron complexwill move more readily from the dialysate into the patient's blood thanwill a larger complex.

While the term “dialysate” is used interchangeably in various contexts,for instance, with respect to hemodialysis and with respect toperitoneal dialysis, it is readily understood by a skilled artisan thata variety of solutes and concentrations of solutes may be used withrespect to various dialysis techniques, and also may vary with respectto the particular needs of a given patient. Because an iron complexselected for use according to the invention is absent in native blood,its presence in dialysate results in diffusion from the dialysate intothe blood. This diffusion is-augmented in preferred aspects of theinvention by the apparent binding of the iron complex to plasmaproteins.

It should be pointed out that the term “complex” may have alternatemeanings in various contexts in the related art and, therefore,clarification of its meaning for purposes of describing the invention isin order. At one level, the term “complex” may be used to describe theassociation between two or more ions to form a relatively low molecularweight non-polymeric composition which exists singly under a given setof conditions. This type of complex may be referred to as a “primarycomplex,” and this is the manner in which the term is to be used herein.As such, the term “primary complex” is used interchangeably herein withthe term “complex” for purposes of describing the invention. Analternate manner in which this term is used in the related field is todescribe the association or agglomeration of a plurality of primarycomplexes into a large macromolecule, or “secondary complex.” Forpurposes of simplicity, these agglomerates are referred to herein asmacromolecules, and are not considered “complexes” as the term is usedto describe the invention.

As an example of the above distinction, ferrous gluconate is acomposition comprising divalent iron ions and gluconate anions. Adivalent iron ion and two gluconate anions form a primary complex ofrelatively low molecular weight (about 450 Daltons) and primarycomplexes of this type do not become agglomerated into macromoleculeswhen dissolved into an aqueous medium. Ferrous gluconate, therefore, isa composition which falls within the scope of the term “complex” herein.Ferric gluconate, however, does not exist as such a complex becauseprimary complexes of trivalent iron ions and gluconate anionsagglomerate together to form very large macromolecules (commonly havinga molecular weight of between about 100,000 and 600,000 Daltons). Assuch, iron complexes according to the invention are identified byselecting a combination of one or more iron ions (either divalent ortrivalent) and one or more anions which interact to form primarycomplexes, but do not become agglomerated into macromolecules.

As such, the present invention provides dialysate compositions, andmethods of using them, which comprise a primary iron complex of one ormore divalent or trivalent iron ions and one or more anions describedherein; which does not become associated or agglomerated to form amacromolecule; which is soluble in an aqueous medium; and which has amolecular size and, correspondingly, a molecular weight, which impartsadvantageous properties with respect to diffusion of the complex througha dialysis membrane.

With respect to solubility, the solubility of a given iron complexaccording to the present invention must be such that the concentrationof the complex in a dialysate solution may be achieved which enables thedesired level of iron delivery to the patient. While conventional beliefin the relevant field is that complexes of the invention would not besufficiently soluble in an aqueous medium to find advantageous use, thepresent inventor has discovered that preferred inventive complexes arehighly soluble.

The particular concentration of iron complex to be dissolved in adialysate according to the present invention is dependent upon theamount of iron desired to be transferred to the patient's blood. Forexample, the amount of iron desired to be transferred in the case of ananemic patient is associated with the known blood building requirementsof the patient. In other words, to determine the desired concentrationof the iron complex in the dialysate, it is first calculated how muchiron the patient needs for building blood cells. The complex willtransfer to the patient at a controlled, definable rate, since the ironcomplex does not exist naturally in the blood. As is readily understoodby one skilled in the art, a higher concentration of iron complex wouldbe needed in peritoneal dialysis techniques than that which would beneeded in extracorporeal hemodialysis techniques due to differing ratesof diffusion with respect to the respective membranes and due to thelower daily volume of dialysate used in peritoneal dialysis. Preferredconcentrations in a given situation may be readily determined by askilled artisan with minimal experimentation.

In a preferred aspect of the invention, iron complexes selected for useare sufficiently soluble in aqueous media to be advantageously includedin a wide variety of formulations to make dialysate concentrates. Asused herein, the term “concentrate” is intended to designate a solutionwherein the solutes are dissolved therein at concentrations much greater(commonly about 30-40 times greater) than a desired dialysateconcentrate. A dialysate concentrate, therefore, has a volume 30-40times less than the actual dialysate and may therefore be pre-mixed andadvantageously shipped and handled much more readily. At the location ofa dialysis procedure, a concentrate is diluted to the proper volume,commonly in the dialysis instrument itself, thereby providing adialysate having suitable solute concentrations for the particular use.

The high concentration of solutes in a dialysate concentrate results ina reduced amount of water which is available to dissolve additionalsolutes. Therefore, the most preferred iron complexes used in accordancewith the invention are highly soluble. The use in the art of dialysateconcentrates is apparently an additional factor which has engendered thebelief that iron complexes, such as those selected in accordance withthe invention, do not have sufficient solubility to be used as describedherein. In contravention of this belief, the present inventor hasdiscovered, for example, that ferrous gluconate is stably soluble insuch a concentrate at levels over 8 grams per 100 ml (dl), thusproviding an iron concentration of about 1 gram per 100 ml. As isreadily ascertainable by one skilled in the art, this would result in aniron concentration in dialysate of approximately 30 mg (30,000 μg) per100 ml after a 35:1 dilution.

An iron complex contemplated for use according to the present inventioncomprises one or more divalent or trivalent iron ions relatively tightlybound to one or more anions to form a low molecular weight iron complex.As used herein, “relatively tightly bound” is intended to mean that theiron ion or ions and the anion or anions will not readily becomedissociated under conditions of the present invention to yield free ironions. The anion may be a natural or a synthetic molecule and may beeither organic or inorganic, so long as it forms a primary complex withdivalent or trivalent iron ions according to the present invention, butdoes not ultimately become associated into a macromolecule and so longas the anion is biocompatible. It is important that the iron ion and theanion remain tightly bound under relevant conditions because anoverabundance of free iron ions in a dialysate and, as a result, in apatient's blood, may cause hemolysis and, if extreme, may cause death.

The anion of an iron complex selected in accordance with the inventionis preferably a multi-polar anion, including for example a divalent ortrivalent anion (e.g. di- or tricarboxylic acids (preferably aliphatic)having up to about 10 carbon atoms, optionally also substituted with oneor more polar groups such as hydroxyl groups); or a monovalent anionwhich has additional polar substituents (such as hydroxyl groups) andwhich is readily complexed with iron ions, such as monohydroxycarboxylicor polyhydroxycarboxylic acids, typically having up to about 10 carbonatoms, especially aliphatic acids of this type such as gluconic acid. Itis contemplated that suitable anions for iron complexes of the inventioninclude, for example, gluconate, sulfate, fumarate, citrate andsuccinate. It is not intended, however, that this list be limiting, andit is within the purview of a skilled artisan to identify anions whichform suitable iron complexes for advantageous use according to theinvention.

The term “low molecular weight iron complex” is intended to designate aniron complex having a size useful for passing through dialysismembranes. As such, iron complexes selected according to the inventionpreferably have a molecular weight of less than about 50,000 and arepreferably non-polymeric. This designation is intended to distinguishiron complexes selected according to the invention from large polymericcompositions and compositions in which primary complexes have becomeassociated with one another to form macromolecules, as discussed above.This molecular weight limitation ensures that iron complexes usedaccording to the present invention are of a size which will pass a widevariety of dialysis membranes used in a wide variety of dialysismethods. It is readily understood by a skilled artisan that many ironcomplexes selected according to the invention may be advantageously usedin both hemodialysis techniques and in intraperitoneal dialysistechniques. Some iron complexes, however, such as those having amolecular weight greater than about 12,000, may not diffuse through manymembranes used in hemodialysis to a suitable degree, but maynevertheless be advantageously used in intraperitoneal dialysistechniques.

With regard to intraperitoneal dialysis, it is expected that an ironcomplex having a molecular weight greater than about 50,000 will not bereadily transported to the patient's blood. In a preferred aspect of theinvention, therefore, the iron complex to be used for intraperitonealdialysis has a molecular weight of less than about 50,000, preferablyless than about 25,000, more preferably less than about 12,000 and mostpreferably less than about 5000.

With regard to extracorporeal hemodialysis methods, it is preferred thatthe iron complex have a molecular weight of less than about 12,000. Morepreferably, the iron complex has a molecular weight of less than about5,000 and most preferably less than about 2,500. It is to be understoodthat the lower the molecular weight of the iron complex and,correspondingly, the smaller the iron complex, the faster the ironcomplex may be incorporated into a patient's blood.

Complexes selected for use according to the invention may be identified,therefore, by their molecular weight, by their degree of solubility inan aqueous medium and by their ability to remain tightly complexed underconditions of the invention. In this regard, a useful way to determinewhether an iron-containing composition falls within the scope of theinvention, is to introduce it into water and, using techniques wellknown to those skilled in the art, to test levels of solubility and todetermine whether the complex becomes dissociated in solution.

According to another aspect of the invention, there is provided adialysate composition having dissolved therein sodium, magnesium,calcium, potassium, chloride, acetate, bicarbonate and an iron complexhaving a molecular weight of less than about 50,000. In certainpreferred embodiments of the invention, the dialysate may alsooptionally include dextrose, a sorbent and/or a surfactant. Preferably,the dialysate composition comprises from about 130 to about 150 mEq/Lsodium, from about 0.4 to about 1.5 mEq/L magnesium, from about 2 toabout 4 mEq/L calcium, from about 1 to about 4 mEq/L potassium, fromabout 90 to about 120 mEq/L chloride, from about 3 to about 5 mEq/Lacetate, from about 30 to about 40 mEq/L bicarbonate and from about 1 toabout 250 μg/dl iron as an iron complex having a molecular weight ofless than about 50,000.

As discussed above, in the field of dialysate preparation, it is commonfor dialysates to be prepared at the site of dialysis, immediatelybefore or simultaneously with the dialysis procedure, by diluting apre-made “dialysate concentrate” having dissolved therein the desiredsolutes at a very high concentration. In this regard, dialysateconcentrates, which are also considered to be a part of the presentinvention, are typically prepared such that the solutes haveconcentrations about 30-40 times greater than the desired concentrationin the actual dialysate fluid, e.g. the preferred concentrations givenabove. The present inventor has discovered that certain iron complexesof the invention, such as, for example, ferrous gluconate, haveexcellent solubility and may find advantageous use in the preparation ofdialysate concentrates.

In this respect, in another aspect of the invention, there is provided adialysate concentrate comprising sodium, magnesium, calcium, potassium,chloride, acetate, bicarbonate and an iron complex having a molecularweight of less than about 50,000. In certain preferred embodiments ofthe invention, the concentrate may also optionally include dextrose, asorbent and/or a surfactant. As stated above, the concentrate may thenbe diluted to the desired dalysate concentration, preferably in thedialysis apparatus itself, and the ratio of concentrate to diluentcombined in the dilution apparatus may be carefully controlled toachieve the desired concentrations of materials dissolved in thedialysate. More preferably, the concentrate comprises the abovecompositions at concentrations from about 35 to about 45 times moreconcentrated than the desired dialysate concentration, even morepreferably between about 34 and about 38 times more concentrated and,most preferably from about 35 to about 37 times more concentrated.

In a preferred aspect of the invention, the iron complex which isdissolved into a dialysate or a dialysate concentrate is ferrousgluconate. Ferrous gluconate is commercially available from FlukaChemical Corporation, Chemika-Biochemika, 980 South Second Street,Ronkonkoma, New York, N.Y. 11779-7238. Ferrous gluconate has been foundby the present inventor to be extremely soluble and to readily diffuseinto blood through a dialysis membrane during conventional hemodialysistechniques. In this iron complex, two gluconate anions are tightlycomplexed with a ferrous ion in the presence of water.

Furthermore, as is demonstrated in Example 1, ferrous gluconatesurprisingly transfers into blood from dialysate in an amountsubstantially higher than that expected based :upon the level oftransferrin in the blood. Normally, it is expected that blood plasma isable to bind no more iron than that held by transferrin, which is themain iron binding protein in the blood. However, in the experiment setforth in Example 1, a ferrous gluconate concentration (125 μg/dl) waspurposely provided in the dialysate which was less than the transferriniron binding capacity (234 μg/dl) in the blood. As is shown in FIG. 1,after only a few minutes of hemodialysis, the transferrin iron level ofthe blood was reached, and the percent saturation of this iron proteinwas 100%. Nevertheless, the iron level in the plasma continued to riseover the next half hour or more of dialysis to a level in the plasmawhich was several times higher than the fully saturated transferrinlevel, and also much higher than the level of iron in the dialysate (125μg/dl).

While it is not intended that the present invention be limited by anymechanism by which it achieves it advantageous result, it appears thatferrous gluconate complexes are bound by another protein in the blood.The mechanism by which this occurs is not known; however, it is evidentthat the invention enables the delivery of iron complexes from dialysateinto blood to much higher levels than previously considered possible.Furthermore, since this iron complex does not become dissolved in bloodplasma water, there should be much less threat of toxicity caused byincreasing free iron levels in the blood. While this result was achievedby delivering ferrous gluconate to blood from dialysate, it is expectedthat a wide variety of compositions having similar characteristics toferrous gluconate would show similar results according to the presentinvention.

The invention will be further described with reference to the followingspecific Examples and associated Figures. It will be understood thatthese Examples are illustrative and not restrictive in nature.

EXAMPLE ONE Transfer of Ferrous Gluconate into Blood

A two liter volume of bovine blood (hematocrit adjusted from 49 to 40with saline) which had been stored with heparin anticoagulation for 24hours was dialyzed using a PAN membrane dialyzer. The volume wasmaintained at 2 liters throughout the experiment by adding saline. Thedialyzer type was FILTRAL 12 and the PAN membranes used had an intrinsicnegative charge and, therefore, tended to bind positively chargedmolecules. The dialysate was created from 20 liters of purified(deionized) water with acetate concentrate (Dial Medical SupplyConcentrate Solution for Acetate Dialysate) in a 1:34 dilution withwater and 10 mg/L ferrous gluconate (1 mg/dl containing 125 μg/dl iron).

A sample of the blood was taken prior to dialysis of the blood andtested for iron content. The iron content of the pre-dialysis blood was110 μg/dl and the transferrin iron binding capacity was 234 μg/dl.Dialysis was then started using the following equipment and conditions:

Blood Pump: Minipump Renal Systems at 300 ml/min (setting 323, ¼″)Dialysate Pump: Travenol at 500 ml/min (setting approximately 92) Bathfor Dialysate: 37° C.The circuit was primed with dialysate, prepared as described above,pumps were adjusted for proper flow, and then the blood side was drainedof dialysate by pulling the Blood In tube out of the dialysis bath andallowing air to fill this side.

Assays were performed to determine plasma iron concentrations at 0, 5,10, 20 and 30 minutes. A plot of iron concentration in plasma versuselapsed time of this experiment is provided in FIG. 1. Though the ironcontent of the dialysate was only 125 μg/dl, it was found that acontinued transfer of iron into the blood proceeded until the plasmalevel reached nearly 500 μg/dl after 30 minutes. This transfer indicatesan avidity of plasma for the iron complex, even higher than the ironbinding capacity of transferrin.

Based upon these results, it is concluded that if the initial rate ofiron transfer to the plasma is continued according to this experimentfor a period of 180 minutes, approximately 4 mg of iron would betransferred to the plasma. Therefore, to transfer 15 mg of iron to thepatient during dialysis, the iron concentration in the dialysate wouldneed to be increased four-fold. As such, increasing the dialysateconcentration of ferrous gluconate to 4 mg/dl (with iron concentrationof 0.5 μg/dl) will result in transfer of 15 mg of iron per dialysistreatment.

EXAMPLE TWO Monitoring of Hemolysis in Experimental Dialysis

To determine whether the method of Example 1 would cause hemolysis(lysis of red blood cells with the liberation of hemoglobin), absorbancedata at 420 and 585 nm was collected for the plasma at various stages ofthe experiment described in Example 1. These data are provided in FIG.2. The increase in absorbance indicates that some degree of hemolysisoccurred during the experiment; however, this level is not higher thanthat of similar experiments conducted without iron in the dialysate.

EXAMPLE THREE Effect on Blood-leak Detection Systems

To determine whether the presence of ferrous gluconate in the dialysatewould interfere with blood-leak detection systems used in hemodialysisprocedures, optical absorbance data for ferrous gluconate at highconcentrations were obtained. These data are provided in FIG. 3. Fromthe plot of FIG. 3, it is apparent that iron can be added to thedialysate without interfering with the detection of hemoglobin indialysate by blood-leak detectors using optical absorbance at either 420nm or 585 nm.

While the invention has been described in detail in the foregoingdescription, the same is to be considered as illustrative and notrestrictive in character, it being understood that only the preferredembodiments have been described and that all changes and modificationsthat come within the spirit of the invention are desired to beprotected.

1. An aqueous dialysate composition comprising: water; about 130 toabout 150 mEq/L sodium; about 0.4 to about 1.5 mEq/L magnesium; about 2to about 4 mEq/L calcium; about 1 to about 4 mEq/L potassium; about 90to about 120 mEq/L chloride; about 3 to about 5 mEq/L acetate; about 30to about 40 mEq/L bicarbonate; glucose; and an iron complex dissolved inthe water, the complex comprising one or more divalent or trivalent ironions and one or more anions and having a molecular weight of less thanabout 50,000, the iron complex having a concentration in the water toprovide an iron concentration of from about 1 to about 250 μg/dl.
 2. Thecomposition in accordance with claim 1, further comprising a memberselected from the group consisting of dextrose, a sorbent and asurfactant dissolved or dispersed in the water.
 3. The composition inaccordance with claim 1, wherein the aqueous dialysate composition issubstantially hypertonic.
 4. The composition in accordance with claim 1,wherein the sodium, magnesium, calcium, potassium, chloride, acetate andbicarbonate are proportioned to prevent excessive ion removal from apatient's blood during dialysis of the blood with the composition. 5.The composition in accordance with claim 1, wherein the iron complex isferrous gluconate.
 6. A method for making an aqueous dialysatecomposition comprising, dissolving into water (i) about 130 to about 150mEq/L sodium, about 0.4 to about 1.5 mEq/L magnesium, about 2 to about 4mEq/L calcium, about 1 to about 4 mEq/L potassium, about 90 to about 120mEq/L chloride, about 3 to about 5 mEq/L acetate, about 30 to about 40mEq/L bicarbonate, and glucose, and (ii) an iron complex comprising oneor more divalent or trivalent iron ions and one or more anions andhaving a molecular weight of less than about 50,000 in an amounteffective to provide an iron concentration in the water of from about 1to about 250 μg/dl, to provide an aqueous dialysate composition.
 7. Themethod in accordance with claim 6, wherein the iron complex is ferrousgluconate.
 8. A method for making an aqueous dialysate composition,comprising: providing a first aqueous solution comprising about 130 toabout 150 mEq/L sodium, about 0.4 to about 1.5 mEq/L magnesium, about 2to about 4 mEq/L calcium, about 1 to about 4 mEq/L potassium, about 90to about 120 mEq/L chloride, about 3 to about 5 mEq/L acetate, about 30to about 40 mEq/L bicarbonate, and glucose; and introducing into thefirst aqueous solution an iron complex comprising one or more divalentor trivalent iron ions and one or more anions and having a molecularweight of less than about 50,000, to provide a second aqueous solutionuseful as an aqueous dialysate composition, the second aqueous solutionhaving an iron concentration of from about 1 to about 250 μg/dl.
 9. Themethod in accordance with claim 8, wherein the complex is introduced ina predetermined amount, the amount being selected based upon the ironneeds of a given patient.
 10. The method in accordance with claim 8,wherein the iron complex is ferrous gluconate.
 11. An aqueous dialysateconcentrate composition, comprising: water; a plurality of electrolytesand glucose dissolved in the water; and an iron complex dissolved in thewater, the complex comprising one or more divalent or trivalent ironions and one or more anions and having a molecular weight of less thanabout 50,000; wherein the electrolytes, glucose and iron complex haveconcentrations in the water whereby the composition is effective fordilution to provide a dialysate composition having about 130 to about150 mEq/L sodium, about 0.4 to about 1.5 mEq/L magnesium, about 2 toabout 4 mEq/L calcium, about 1 to about 4 mEq/L potassium, about 90 toabout 120 mEq/L chloride, about 3 to about 5 mEq/L acetate, about 30 toabout 40 mEq/L bicarbonate, glucose, and an iron concentration of fromabout 1 to about 250 μg/dl.
 12. The aqueous dialysate concentratecomposition in accordance with claim 11, further comprising a memberselected from the group consisting of dextrose, a sorbent and asurfactant dissolved or dispersed in the water.
 13. The aqueousdialysate concentrate composition in accordance with claim 11, whereinthe electrolytes have a concentration in the water of from about 7692mEq/L to about 12,980 mEq/L.
 14. The aqueous dialysate concentratecomposition in accordance with claim 11, wherein the iron complex isferrous gluconate.
 15. A method for making an aqueous dialysateconcentrate composition comprising, dissolving into water (i) aplurality of electrolytes and glucose, and (ii) an iron complexcomprising one or more divalent or trivalent iron ions and one or moreanions and having a molecular weight of less than about 50,000, toprovide an aqueous dialysate concentrate composition; wherein theelectrolytes, glucose and iron complex have concentrations in the waterwhereby the composition is effective for dilution to provide a dialysatecomposition having about 130 to about 150 mEq/L sodium, about 0.4 toabout 1.5 mEq/L magnesium, about 2 to about 4 mEq/L calcium, about 1 toabout 4 mEq/L potassium, about 90 to about 120 mEq/L chloride, about 3to about 5 mEq/L acetate, about 30 to about 40 mEq/L bicarbonate,glucose, and an iron concentration of from about 1 to about 250 μg/dl.16. The method in accordance with claim 15, wherein the electrolytes insaid concentrate composition have a concentration in the water of fromabout 7692 mEq/L to about 12,980 mEq/L and wherein the iron complex insaid concentrate composition has a concentration in the water effectiveto provide an iron concentration in the water of from about 0.03 toabout 10 mg/dl.
 17. The method in accordance with claim 15, furthercomprising introducing into the water a member selected from the groupconsisting of dextrose, a sorbent and a surfactant.
 18. The method inaccordance with claim 15, wherein the iron complex is ferrous gluconate.